The pathogenesis and epidemiology of catheter-related infection with pulmonary artery Swan-Ganz catheters: A prospective study utilizing molecular subtyping

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Abstract

To delineate the pathogenesis and epidemiology of catheter-related infection with Swan-Ganz pulmonary artery (PA) catheters, a prospective clinical study of hospitalized adult medical and surgical patients was done. Role of catheter material was assessed by randomizing insertions to heparin-bonded PA catheters made of polyvinylchloride or polyurethane. Sources of infection and pathogenesis were studied by culturing skin, the introducer, the PA catheter tip, all hubs, infusate from each lumen, and the extravascular portion of the PA catheter beneath the external protective plastic sleeve. Concordance between isolates from sources and infected catheters was determined by speciation, antibiogram, and for coagulase-negative staphylococci, plasmid profile analysis. Risk factors for infection were determined by stepwise logistic regression.

Overall, 65 (22%) of 297 Swan-Ganz catheters showed local infection of the introducer (58 catheters) or the intravascular portion of the PA catheter (20 catheters); only two catheters (0.7%) caused bacteremia. Eighty percent of infected Swan-Ganz catheters (the introducer or PA catheter) showed concordance with organisms cultured from skin of the insertion site, 17% with a contaminated hub and 18% with organisms contaminating the extravascular portion of the PA catheter beneath the sleeve. Isolates from infected PA catheters were most likely to show concordance with concomitantly infected introducers (71%). Cutaneous colonization of the insertion site with > 102 cfu/10 cm2 (relative risk [RR] 5.5; p < 0.001), insertion into an internal jugular vein (RR 4.3; p < 0.01), catheterization >3 days (RR 3.1; p < 0.01), and insertion in the operating room using less stringent barrier precautions (RR 2.1; p = 0.03) were each associated with a significantly increased risk of catheter-related infection. The risk of bacteremic infection with Swan-Ganz catheters is now low, in the range of 1%, with reasonable care. Swan-Ganz catheters are vulnerable to contamination from multiple sources, but the patient's skin is the single most important source of organisms causing invasive infection, which in most cases involves the introducer rather than the PA catheter. Heavy colonization of the insertion site, percutaneous insertion in the internal jugular vein rather than subclavian vein, catheterization longer than 3 days, and insertion with less stringent barrier precautions significantly increase the risk of catheter-related infection. These findings hold promise for application to management of Swan-Ganz catheters and research in catheter design to reduce the risk of catheter-related infection.

References (69)

  • HJC Swan et al.

    Catheterization of the heart in man with use of a flow-directed balloon-tipped catheter

    N Engl J Med

    (1970)
  • SO Heard et al.

    Influence of sterile protective sleeves on the sterility of pulmonary artery catheters

    Crit Care Med

    (1987)
  • JJ Applefeld et al.

    Assessment of the sterility of long-term cardiac catheterization using the thermodilution Swan-Ganz catheter

    Chest

    (1978)
  • L Michel et al.

    Infection of pulmonary artery catheters in critically ill patients

    JAMA

    (1981)
  • S Singh et al.

    Catheter colonization and bacteremia with pulmonary and arterial catheters

    Crit Care Med

    (1982)
  • JC Pinilla et al.

    Study of the incidence of intravascular catheter infection and associated septicemia in critically ill patients

    Crit Care Med

    (1983)
  • KD Boyd et al.

    A prospective study of complications of pulmonary artery catheterizations in 500 consecutive patients

    Chest

    (1983)
  • W Kaye et al.

    Radial and pulmonary artery catheter-related sepsis

    Crit Care Med

    (1983)
  • J Groeger et al.

    Contamination shields for pulmonary artery catheters

    Crit Care Med

    (1983)
  • HM Horst et al.

    The risks of pulmonary arterial catheterization

    Surg Gynecol Obstet

    (1984)
  • JJ Miller et al.

    Comparison of the sterility of long-term central venous catheterization using single lumen, triple lumen, and pulmonary artery catheters

    Crit Care Med

    (1984)
  • P Ricard et al.

    Protection of indwelling vascular catheters: incidence of bacterial contamination and catheter-related sepsis

    Crit Care Med

    (1985)
  • ML Myers et al.

    Pulmonary artery catheter infections

  • MH Parsa et al.

    Complications of pulmonary artery catheterization

    Problems Gen Surg

    (1985)
  • J Damen et al.

    A prospective analysis of 1400 pulmonary artery catheterizations in patients undergoing cardiac surgery

    Acta Anaesthesiol Scand

    (1986)
  • A Senagore et al.

    Pulmonary artery catheterization: a prospective study of internal jugular and subclavian approaches

    Crit Care Med

    (1987)
  • JA Hudson-Civetta et al.

    Risk and detection of pulmonary artery catheter-related infection in septic surgical patients

    Crit Care Med

    (1987)
  • JH Levy et al.

    Contamination reduction during central venous catheterization

    Crit Care Med

    (1988)
  • MA Fisher et al.

    Pulmonary artery catheters: risk factors for infection

  • S Eyer et al.

    Catheter-related sepsis: prospective, randomized study of three methods of long-term catheter maintenance

    Crit Care Med

    (1990)
  • HW Horowitz et al.

    Central catheter-related infections: comparison of pulmonary artery catheters and triple lumen catheters for the delivery of hyperalimentation in a critical care setting

    J Parenter Enteral Nutr

    (1990)
  • DM Maki

    Infections due to infusion therapy

  • MA Pfaller et al.

    Laboratory, clinical, and epidemiological aspects of coagulase-negative staphylococci

    Clin Microb Rev

    (1988)
  • GD Christensen et al.

    Characterization of clinically-significant strains of coagulase-negative staphylocci

    J Clin Microbiol

    (1983)
  • Cited by (0)

    Dr. Leonard A. Mermel is now with the Division of Infectious Diseases, The Rhode Island Hospital, Providence, Rhode Island.

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